Influence of Listen-Establish-Adopt-Reinforce-Name-Strengthen Nursing on Nutritional Status in Older Adults with Diabetes Mellitus

Summary

This study confirmed the high application value of the Listen-Establish-Adopt-Reinforce-Name-Strengthen care model as a patient-centered nursing model, demonstrating that it substantially improved blood glucose control, enhanced self-care ability, and optimized nutritional status in patients with diabetes mellitus.

Abstract

Diabetes mellitus (DM) is a widespread chronic metabolic illness around the world, and prolonged hyperglycemia not only causes a variety of problems but also affects metabolic and immunological activities, compromising patients' nutritional status. The Listen-Establish-Adopt-Reinforce-Name-Strengthen (LEARNS) nursing paradigm, based on a patient-centered concept, is a new strategy that aims to foster self-directed learning, improve nurse-patient engagement, increase self-care awareness, and encourage two-way communication. This study looked at the effect of LEARNS nursing on the nutritional status and general health indices of older persons with DM. A total of 168 hospitalized patients aged 60 years or older were involved, with 89 in the LEARNS group and 79 receiving standard treatment. Propensity score matching was used to reduce confounding bias, and the intervention lasted four weeks. After the intervention, patients in the LEARNS group had significantly improved glycemic markers, including reduced HbA1c, FPG, and 2hPG values (P < 0.05). Self-management capacity improved, as evidenced by higher scores on the Chinese Diabetes Management Self-Efficacy Scale. Nutritional indicators such as serum albumin (ALB), hemoglobin (HGB), total serum protein (TSP), and transferrin (TRF) increased, whereas the proportion of high-risk patients identified by the PG-SGA malnutrition score dropped. Quality-of-life assessments also showed improvement, with higher Health-Promoting Lifestyle Profile (HPLP-II) and lower Pittsburgh Sleep Quality Index (PSQI) ratings. The LEARNS group had a considerably higher patient satisfaction rate (92.13%) compared to the control group (P < 0.05). Overall, the data demonstrate that the LEARNS nursing model improves nutritional status, self-management efficacy, and quality of life in senior diabetic patients while also improving glucose control. The study's shortcomings include a single-center design and a short follow-up time. More studies with larger samples and longer periods of observation are needed to confirm long-term effects.

Introduction

Diabetes mellitus (DM), one of the most common chronic metabolic diseases, affects approximately 456 million people worldwide suffer from DM, and it is expected to reach 629 million by 2045, according to statistics from the World Health Organization¹. Due to the influence of persistent hyperglycemia in the body, DM patients are not only susceptible to cardiovascular diseases, neuropathy, and other complications, but may also develop serious complications such as uremia². Research shows that among the annual unnatural deaths worldwide, the proportion of deaths due to DM-associated complications is as high as 20%-30%, second only to malignancies³. DM is a life-long disease that can't be cured. In addition to the use of drug therapy to control blood glucose (BG), long-term nursing interventions are also needed to address the patient's unhealthy habits in terms of diet, exercise, etc. Due to the high prevalence of DM among older adults in China, coupled with a decline in their cognitive comprehension and memory loss, they often have erroneous disease awareness, which can easily lead to fluctuations in BG levels that affect their health^4,5. Meanwhile, persistent hyperglycemia can lead to impaired glucose utilization, excessive secretion of inflammatory factors, and accelerated protein decomposition, causing metabolic and immune dysfunction in patients, and increasing the risk of complications of DM⁶. Therefore, the nutritional status of DM patients is also a priority that deserves clinical and patient attention.

Traditional DM education often fails to address the unique needs of elderly patients, such as cognitive decline, multimorbidity, and low health literacy. Standardized materials may not be adaptable to individual learning paces, and limited interaction reduces engagement. These factors contribute to poor adherence and suboptimal outcomes in older populations^7,8. Hence, there is an urgent need to find a more suitable nursing plan for DM patients. Listen-Establish-Adopt-Reinforce-Name-Strengthen (LEARNS) nursing is a new nursing model that takes the patient as the center of care and achieves two-way learning with patients by promoting patients' self-learning and joint participation in disease knowledge learning and improving patients' self-care awareness⁹. In recent years, LEARNS nursing has been increasingly applied in clinical practice, especially among elderly patients with various chronic diseases, with its positive role being repeatedly affirmed^10,11. This study extends existing evidence by focusing on nutritional outcomes in elderly DM, a high-risk yet understudied subgroup.

Accordingly, by observing the influence of LEARNING care on the nutritional status of DM patients, this study provides more reliable and comprehensive reference and guidance for the future clinical treatment of DM.

Protocol

The current study was examined and authorized by the Medical Ethics Committee of Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University) under IRB Approval No. [20241-245]. All study procedures involving human participants adhered to the institutional and/or national research committee's ethical requirements, as well as the principles established in the Declaration of Helsinki and its subsequent revisions or comparable ethical standards. The equipment and the software used are listed in the Table of Materials.

1. Patients

An analysis of existing data was conducted. The participants were 168 DM patients admitted to Hunan Province People's Hospital from May 2024 to October 2024. Inclusion criteria: Meeting the diagnostic criteria for DM¹²; intact clinical data; age >60 years old. Exclusion criteria: Organ failure; malignant tumor(s); mental illness; poor treatment compliance; withdrawal from the research for other reasons. Patients were allocated to groups based on the nursing modality they actually received during hospitalization. To minimize selection bias, we performed propensity score matching using age, gender, BMI, and diabetes duration as covariates, achieving a 1:1 match between groups. All eligible patients meeting the inclusion criteria during the study period were included (consecutive sampling). Post-hoc power analysis revealed that with n = 168, the study had 85% power to detect a medium effect size (d=0.5) at α=0.05. Among them, 89 patients receiving LEARNS nursing were included in the research group, and the other 79 patients receiving routine nursing were included in the control group. All the subjects signed informed consent forms.

2. Nursing methods

1. Routine nursing
   Patients had their personal information registered after admission. Oral education was given to inform them of health education knowledge, such as the prevention and treatment of DM and complications. Additionally, patients were informed about the importance of a balanced and reasonable diet, advised to allocate calories reasonably and control their intake of high-sugar foods, and provided with educational manuals for reference. Furthermore, the nurse measured the patient's BG regularly every day and guided the patient's medication. Moreover, psychological counselling was provided, and patients were instructed to maintain a good state of mind and cooperate with treatment. Patients were also advised to exercise moderately daily and to have adequate rest.
2. LEARNS nursing
   ​In addition to the above measures, LEARNS nursing was implemented in the research group. First, a LEARNS nursing health education group was established, with specific job responsibilities and content assigned to each member. After developing a nursing plan, systematic learning and training were conducted to ensure the smooth implementation of nursing interventions (lasts for 1 week).
   1. Listen: Initial assessment interviews (recorded duration: 30-45 min)
      Before care implementation, nursing staff first listened and communicated with patients to understand their disease-related information and needs, and established a good nurse-patient relationship through communication, so as to gain the trust of patients and enhance their treatment compliance.
   2. Establish: Individualized care plans based on assessment
      After comprehensively understanding patients' actual conditions, concepts, personalities, etc., planned and multi-mode health education was carried out according to the different conditions of patients.
   3. Adopt: Educational sessions (average 3 sessions/week, 4 weeks)
      In the process of collaborative learning, medical staff guided patients to identify problems, raise questions, and work together to solve them. Additionally, the patient's mastery level was assessed in a timely manner, and targeted re-education was implemented.
   4. Reinforce: Follow-up evaluations and reinforcement
      Furthermore, nurses paid attention to changes in patients' psychological states, attached importance to improving their health awareness and self-management efficiency, and communicated with them in a timely manner to obtain feedback information, further improving the methods. Moreover, patient evaluations of the effectiveness of nursing interventions were recorded.
   5. Name-Strengthen: Discharge planning and community linkage
      After patients were discharged from the hospital, nursing staff maintained contact with them through the Internet and closely monitored their conditions in a timely manner. New knowledge was disseminated to guide the correct use of medications. Patients were also encouraged to exercise moderately and adopt healthy eating habits. Adherence to LEARNS protocols was monitored through a review of nursing records, including documentation of session completion rates (target: 80% or higher) and patient feedback logs. Nurses received monthly audits to ensure consistency. The nursing intervention for all patients began at admission and continued for 4 weeks after discharge.

3. Outcome measures

Fingertip blood samples were collected from patients with a glycosylated hemoglobin (HbA1c) analyzer and the blood glucose (BG) monitor to compare BG control performance before and after intervention. The BG monitoring indexes mainly included HbA1C, fasting plasma glucose (FPG), and 2h postprandial BG (2hPG). The Diabetes Management Self-Efficacy Scale-Chinese Version (C-DMSES)¹³ was employed for the assessment of self-care ability before and after intervention from four dimensions, namely diet, exercise, medication, and BG monitoring; a higher score suggests a better self-care ability. The health behaviors of patients were evaluated using the Health-Promoting Lifestyle Profile (HPLP II)¹⁴; the score is positively associated with health behaviors. Patients' sleep quality was assessed using the Pittsburgh Sleep Quality Inventory (PSQI)¹⁵; the score range is 0 to 21, with higher scores indicating worse sleep quality. Nutritional status indicators, including albumin (ALB), hemoglobin (HGB), total serum protein (TSP), and transferrin (TRF), were measured in fasting venous blood samples collected in the early morning from both patient groups. An automatic biochemical analyzer was used for detection. The malnutrition risk level was evaluated by the Patient-Generated Subjective Global Assessment (PG-SGA)¹⁶, mainly assessing weight loss, severity of comorbidities, nutritional intake, gastrointestinal function, and age. According to the scoring results, the patient's malnutrition risk level was rated as none (0-1), low (2-3), medium (4-8), or high (≥9). An anonymous nursing satisfaction assessment was carried out at discharge, with the results classified as satisfied, basically satisfied, barely accepted, and dissatisfied. Total satisfaction = (satisfied cases+basically satisfied cases)/total number of people ×100%. All scales were used in their validated Chinese versions: C-DMSES (Cronbach's α=0.89 in Chinese elderly), HPLP-II (ICC=0.84), PSQI (α=0.82), and PG-SGA (validated in Chinese cancer patients).

4. Statistical methods

This study used SPSS 23.0 for data analysis. Gender, nursing satisfaction, and other categorical variables were represented by (%) and compared using χ² tests. Age, FPG, and other continuous variables are presented as mean ± standard deviation (SD) and were compared using independent-sample and paired t tests. No data were missing in this study. Multivariable linear regression adjusted for baseline differences, including comorbidities and medication use. Bonferroni correction addressed multiple comparisons. Effect sizes (Cohen's d) were calculated for all continuous outcomes. In this study, P < 0.05 was considered a statistically significant difference.

Results

Comparison of clinical data
The research group was not statistically different from the control group in terms of age, sex, body mass index, disease course, and other clinical data (P > 0.05, Table 1).

Comparison of BG
HbA1c, FPG, and 2hPG did not differ markedly between groups before care (P > 0.05). After nursing, HbA1C, FPG, and 2hPG decreased in both groups, and the reduction in the research group reached 30...

Discussion

This study explored the influence of LEARNS nursing on elderly DM patients. The research results showed that LEARNS nursing not only helped patients better control their BG levels, but also improved their nutritional status in all aspects, confirming the high application value of LEARNS nursing in future care for DM.

For DM patients, BG control is the key to ensuring their health. Since there is no clinical cure for DM at present, patients should strictly control their dietary intake in daily ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Automatic biochemical analyzer	Autobio	B2B 2162021	An automatic detection device based on photoelectric colorimetric principle
Blood glucose monitor	Sinocare	4XX5CR00858	An instrument used to measure blood glucose levels
Glycosylated hemoglobin analyzer	Hunan Yonghe Sun Biotechnology	YH60CHB00025	An instrument used to measure HbA1c
SPSS23.0	IMB	v.23.0	A professional statistical analysis software